EMERGENCY FORM

INSTRUCTIONS TO PARENTS/GUARDIANS:

(1) Complete all items on this side of the form. Sign and date where indicated.

(2) If your child has a medical condition which might require emergency medical care, complete the back side of the form. If necessary, have your child’s health practitioner review that information.

NOTE: THIS ENTIRE FORM MUST BE UPDATED ANNUALLY.

Child’s Name ______Birth Date ______

Enrollment Date ______Hours & Days of Expected Attendance ______

Child’s Complete Home Address ______

Mother/Guardian’s Name ______

Home Telephone ______

Employer/School ______

Complete Home Address (If different from above) ______

Work Telephone ______Cellular Phone ______

Father/Guardian’s Name ______

Home Telephone ______

Employer/School ______

Complete Home Address (If different from above) ______

Work Telephone ______Cellular Phone ______

Name of Person Authorized to Pick-up Child (daily)______

Last First Relationship to Child

Address ______

Street/Apt# City State Zip Code

When parents/guardians cannot be reached, list at least one person who may be contacted to pick up the child in an emergency:

1. Name ______Telephone (H) ______(W) ______

CompleteAddress______

2. Name ______Telephone (H) ______(W) ______

Complete Address______

(Initials/Date) (Initials/Date) (Initials/Date) (Initials/Date)

OCC 1214 (Revised 7/15) - Page 1 of 2 - All previous editions are obsolete

NSTRUCTIONS TO PARENT/GUARDIAN:

IN EMERGENCIES requiring immediate medical attention, your child will be taken to the NEAREST HOSPITAL EMERGENCY ROOM. Your signature authorizes the responsible person at the child care facility to have your child transported to that hospital.

Signature of Parent/Guardian ______Date ______

ANNUAL UPDATES ______

Child’s Physician or Source of Health Care ______Telephone ______

Complete Address______

1) Complete the following items, as appropriate, if your child has a condition(s) which might require emergency medical care.

(2) If necessary, have your child’s health practitioner review the information you provide below and sign and date where indicated.

Child’s Name: ______Date of Birth: ______

Medical Condition(s): ______

______

Medications currently being taken by your child: ______

______

Date of your child’s last tetanus shot: ______

Allergies/Reactions: ______

______

EMERGENCY MEDICAL INSTRUCTIONS:

(1) Signs/symptoms to look for: ______

______

(2) If _ signs/symptoms appear, do this: ______

(3) To prevent incidents: ______

______

______

OTHER SPECIAL MEDICAL PROCEDURES THAT MAY BE NEEDED: ______

______

______

______

COMMENTS: ______

______

______

______

______

Note to Health Practitioner:

If you have reviewed the above information, please complete the following:

______

Name of Health Practitioner Date

______(_____)______

Signature of Health Practitioner Telephone Number

OCC 1214 (Revised 7/15) - Page 2 of 2 - All previous editions are obsolete.